I think that the more swagger and sarcasm involved is present in an argument, the less evidence there usually is to back it up. I find this post particularly disturbing in its tone, and its lack of real obstetrical knowledge to back up the assumptions mixed among the insults.

I am not happy with the extreme bias and apparent interest in just supporting a world view (while criticizing the same in others, ironically) as opposed to actual truth finding in the few posts I read at this site, and I don’t think this site is going to be worth much investment of my time and limited stress reserve. I was pointed at this post, which discusses a recent, flawed meta-analysis of home births that includes unplanned, precipitous births at home in its analysis, instead of using an “intent to treat” model. I felt the need to answer this particular post, which simply assumes at the end that precipitous, unplanned home births only happen in snow storms, and would have no confounders associated with poor neonatal outcomes. With no discussion of the pathology or etiology of precipitous delivery or neonatal morbidity, of course, and no citations.

“The Pang study, for example, contributed a large chunk of the population analyzed for neonatal deaths, but has been widely debated and criticized for including unplanned home births in its analysis of neonatal death at home birth.”

How could this possibly make a difference? It was limited to near or full-term deliveries. People simply don’t have many near full term at home accidentally. These have to be things like getting snowed in.

Do you have any data about what percentage this is? Did you know you can calculate how big the effect would have to be to shift the results. (hint: if it is huge, than it can’t make a difference) Have you done that? If you haven’t why do bring this up?

Here is my reply:

(Reposted with the html fixed)

I can tell you how it could make a difference, even at full term delivery.

The next few points are all taken from Gabbe’s Obstetrics. 2% of labors in the United States are precipitous. This is not just an issue during snow storms.

Another way a precipitous labor may be associated with poor outcomes? Maternal cocaine use is a risk factor for precipitous labor, and is independently linked with poor neonatal outcomes. And, it’s linked with not having adequate prenatal care or a trained attendant at the delivery.

Also, placental abruption is associated with precipitous delivery. Also independently associated with poor neonatal outcomes, including hypoxia. According to Mahon’s retrospective analysis of TERM precipitous deliveries, it is the ones that are really abrupt (above the 95%) that are associated with neonatal mortality. You know, the ones that come so fast you can’t make it to the hospital, and end up being unintended home births.

Also according to Gabbe, precipitous labor is also associated with uterine tetany, which may cause intrapartum fetal hypoxia or fetal distress, which are related to poor outcomes.

Hm, it looks like that site is trying to be a (poorly done) counter-point to ‘My Ob said what”

What amazes me about the assumptions made about unattended home deliveries. Mind you, I’ve seen neither study referred to here on paper, but beyond precipitous deliveries, what about people who worry that CPS will take their child(ren) away if they give birth in a hospital? Who have precarious transport situations and don’t want to call an ambulance because they worry they might have to pay for it? Who are drug addicts and don’t know/care about the signs of labor?

…if the person I suspect is actually behind this, it’s amazing to me that they would assume a suburban, middle-class, socially and financially secure family is behind more or less every birth in the US, when they constantly accuse ‘birth junkies’ of trying to force their privileged white middle class birth fantasies on everyone.

The author(s?) clearly has some serious issues with the Cochrane Collaboration, like:
“The Cochran Reviews is an organization devoted to poor quality meta-analysis via its promotion of a very simplistic, cookbook method that is made worse by interpretations by its mostly amateurish researchers. ”

And yet they don’t appear to take the time to get the correct spelling of the organization’s name. The only place it is spelled correctly is when they quote from someone else’s research.
So which of these is true?:
1) They don’t know what the correct name is, which makes you wonder how much else they don’t know about the organization.
2) They don’t really care what the correct name is because they don’t take the time to double check.
3) They do know the difference and use the incorrect spelling as an intentional sign of disrespect.
So, ignorance, apathy, or malice?

And the other funny thing is that I would expect a person who says “I used to teach statistics” to be able to recognize the difference between a neonatal death rate of 3.4 per thousand, and 3.4 per ten thousand (or 0.34 per thousand), and to know which value is smaller or greater than 1 per 1000.

As far as the results of the Pang study, we have the question regarding unplanned home births:
“How could this possibly make a difference? ”
Well, quite easily. The Pang study shows an adjusted OR for neonatal death of 1.99, with a 95% CI of 1.06 – 3.73. What that means is that if only one or two of the deaths in the home birth group were erroneously included in this group (because they were not planned home births), the lower bound of that CI would be less than 1.0. In other words, it would make the conclusions of the paper no longer statistically significant. So, no, it would not take a huge number of miscoded deaths to change the result, because the absolute difference between the groups is not huge, and because the number of actual incidents is quite small.

They posted a really rude response to my comment that continued along the lines of insult-what-you-cannot-refute. They acknowledged that 5% of these home births did not even have a clinician to provide an APGAR score, but don’t think that this might make a difference for a poor outcome that is as vanishingly rare as neonatal death. I am not bothering answering on their site. Someone told me once to not get in a pissing contest with a skunk.

“Well, quite easily. The Pang study shows an adjusted OR for neonatal death of 1.99, with a 95% CI of 1.06 – 3.73. What that means is that if only one or two of the deaths in the home birth group were erroneously included in this group (because they were not planned home births), the lower bound of that CI would be less than 1.0. In other words, it would make the conclusions of the paper no longer statistically significant. So, no, it would not take a huge number of miscoded deaths to change the result, because the absolute difference between the groups is not huge, and because the number of actual incidents is quite small.”

OK great. Why don’t you tell us all about the “statistical significance” of this confidence ratios?

And why don’t you re-calculate with however many misclassifications you need to get them to be “no longer statistical significance”, and let us all know what that number is. Let us know what the ratio is too.

It’s difficult to argue with political propaganda, and that is all this meta-analysis is. Anyone with a decent understanding of epidemiology and statistics can see how ridiculous the meta and the Pang studies are.

And speaking of CIs, way to completely miss the point that Amy R was making about a CI wide enough to drive a truck though. A wide CI is a sign of an underpowered study – and consequently a weak result. Which is why it is very misleading to promote the Wax paper as “the largest meta-analysis of home birth” which showed a “doubling or tripling of neonatal death rate”. Because the wide CI found in this subanalysis shows that this particular result is not at all strong, and surely should not be highlighted as the primary finding in the Wax paper.

“And speaking of CIs, way to completely miss the point that Amy R was making about a CI wide enough to drive a truck though. A wide CI is a sign of an underpowered study – and consequently a weak result”

And when it gets “powered up” what happens to the CI? Doe it get bigger or smaller? stay the same? Can’t tell?

And if the entire “underpowered” CI in question is already all to one side, what happens?

And for extra credit, how does all this fit in to the playskool/kiddie kalculus/paint-by-numbers thing?

If you want to dispute that the results reported by Wax regarding neonatal death are objectively statistically underpowered and weak, compared to the results in the same paper for perinatal death, go ahead.

You are trying to make this sound like it is a hard question. It’s not.

Comparing the results reported by Wax for the results on neonatal death to the results in the same paper on perinatal death:
1) An analysis that includes 48,000 subjects is underpowered compared to an analysis that includes over 500,000 subjects.
2) An analysis that includes incidents (deaths) numbering several dozen is underpowered compared to an analysis that included incidents numbering several hundred.
3) An analysis with an OR CI of (1.32 – 6.25) is underpowered compared to an analysis with an OR CI of (0.77 – 1.18).

If these two analyses were anywhere near the same in size, then it would make sense to use more detailed tools and formulas to compare their relative strength. But it’s not even close. It’s a waste of time to argue further.
But if you want to show us your statistical prowess, and demonstrate with real numbers why the result for neonatal death is better, or stronger, or more powerful, or somehow more closely approximating a universal truth, compared to the result for perinatal death, then put on your tool belt and prove it.

>> So, if the CI was about .3-6, the true, when it gets “powered up” (BTW, how does one do that statistically?) will probably be around 3.

This is really not true. Theoretically the most common true value is in the center, but in aggregate it is most likely that it is not near the center, as there are many other values. In a standard distribution, the center is still only about 20% of the volume of the curve.

The point is that you don’t know where in the distribution the truth. If we could just assume it was in the middle we wouldn’t need more power.

And then there’s that whole weird vibe that says “I’m more grownupper than you are and I can prove it because you all play Paint-By-Number and Playskool and amateurish cookbooky stuff and I’m so above all that”. Way to convincingly display your professional bona fides.

Yeah, I found the tone really rude and disturbing. If you’re going to complain about paint-by-numbers or a cookbook approach, link to citations about what is wrong with these approaches, critique them specifically, not just with random vague insults, and offer an alternative.

Thanks for the links, however irrelevant, but you are completely confused. If you had actually read the study before you opened your keyboard, you would know that accidental home births of any type, precipitous or not, were eliminated by limiting the analysis to full-term and to those who listed a medical attendant at home. Nevertheless, the mantra in the Midwifery community is the opposite of reality.

Home birth is only one kind of Out of Hospital Birth. The others are transport births/deaths (in an emergency medicine vehicle, going between locations, which are almost all of doctors’ OOH) and well, anywhere else that is not a home, a hospital, or emergency medicine vehicle.

Full-term moms who want the hospital but do not make, are not necessarily precipitous. They may simply be rural and have too far to go. And most of those are not home deliveries, they are Truck Stop deliveries, side of the highway, in the police car etc. In other words, they are out of hospital, but they are not home.

To deliver 1) at home 2) at full term and 3) involuntarily usually requires something preventing her from venturing out – no truck, snowed in, bridge washed out, or the Baby Daddy from Hell. To know and consider such things requires not only medical knowledge, but also sensitivity to women of all backgrounds, listening to their stories, knowing how they live. Some segments of this debate lack that.

Pang limited the study to Full-Term to eliminate the Pre-termers that can sometimes accidentally deliver at home as the woman may not recognize the often much less intense pre-term labor and the baby is small enough to come out easily and quickly. These, of course, have high deaths rates as well. Pang et al further cut down on the unintended emergency deliveries by getting rid of those listed as attended by EMTs or lay people or no one but mom.

To discredit the study on the grounds the home birth data was “polluted” with a bunch of unintentional Full-term home birthers oh, who also had a midwife or doc’s name of the certificate as the attendant and had no known complications requires quite a bit of work on your part.

These criteria are a fairly decent approximation for intention to treat unless you can show evidence of this phenomenon of full-term women unintentionally dropping their babies at home in say in 10 minutes flat (they can’t even get out th door you know) while say, doing the ironing. Explain this to me, how does this happen so much? Plus, this sub-group has to have an extraordinarily high death rate. If anything, the bias was in favor of the midwives, who could easily have their deaths misattributed to doctors after transport to hospital. That’s perhaps why this study found only 2 X increase, instead of the usual 3 X.

The “homework” for the homebirth crowd who want to discredit this study remains the same.
What percentage of these apparently uncomplicated full-term deaths classified as homebirth were really unintended home births?
There’s only about 5% of the homebirth crowd that didn’t have APGARs. In the hospital part, it was nil. So, the vast majority of study subject s had someone at their birth who thought they could do APGARs, so presumably this was a medical person of some sort. Don’t you think? As mentioned above, EMTs and such don’t get into the study. The wildcard doesn’t seem to be too terribly big here.http://journals.lww.com/greenjournal/Fulltext/2002/08000/Outcomes_of_Planned_Home_Births_in_Washington.9.aspx#P48

If this is an unfindable number, then how many of the home birth classified deaths would have to be unintended full-term women for the gap to not be substantial? Since the death rate doubled, the magnitude of this alleged error would have to be enormous to change the basic conclusion.

From Pang:
“we defined planned home births as those singleton newborns of at least 34 weeks’ gestation who were delivered at home and who had a midwife, nurse, or physician listed as either the birth attendant or certifier on the birth certificate (if an attendant is not listed on the birth certificate, then the person listed as the certifier attended the delivery). In addition, singleton newborns with gestational age of at least 34 weeks who were born after transfer from home to a medical facility were considered to be planned home births if their birth certificates indicated that delivery was initially attempted at home by a health care professional.”

“To minimize misclassification of intended and unintended home births, the main analysis was confined to births in which there were no recorded pregnancy-related complications (6133 home births, 10,593 hospital births), because it is unlikely that women with one or more of these complications actually intended to deliver at home.”

But thanks for showing how Midwifery supporters mouth meaningless excuses to deny their bad data no matter how illogical they are.

I already answered this in the original post. Sorry it took me so long to respond. I am on my clinical rotations, and I have a serious problem with your tone and am questioning replying at all. Argue my points on their merits. Don’t call my points, with detailed explanation with citations, about how GBS pneumonia and extreme precipitous labor could influence TERM neonatal mortality rates illogical.

Also, Washington state does not require any training for someone to attend a homebirth. You can be a doula, or a layperson, and attend a homebirth, even assign APGARs!

My citations include information about morbidity and mortality from TERM precipitous delivery. The 5% who didn’t even have APGAR scores is more than a magnitude higher than the difference in neonatal mortality – how is that not significant?

Also, if you are so confident about how none of these should count, maybe you could get a letter published in AJOG like Janssen and Klein have, making many of the same critiques made by me and the other commenters on this site and others. AJOG doesn’t seem to think that physician and professor of public health are mouthing meaningless excuses, and my time is too valuable to argue with someone who cannot discuss an issue respectfully.

I am going to end my last reply to the so called “truth squad” with one quote from the article:

“The analysis excluding
studies that included home births attended
by other than certified or certified
nurse midwives had findings similar to
the original study, except that the ORs
for neonatal deaths among all (OR, 1.57;
95% CI, 0.62–3.98) and nonanomalous
(OR, 3.00; 95% CI, 0.61–14.88) newborns
were not statistically significant.”

Maybe I just shouldn’t call you….. The home subjects in the Washington study were a) Term births b) had a midwife or physician listed as the attendant, and c) born in home or after transport from a midwife or physician attended home attempted delivery. Precipitous or not was not an issue. Your so-called points could not be more tangential and irrelevant.

You seem to further not realize the urban precipitous deliveries are still mostly born in the hospital. And that most are fine. Most importantly, you seem unaware of how much official scrutiny surrounds a baby that has died outside a medical setting or dies shortly after arrival. Law enforcement and social services get notified in most cases. The chance of misclassification of death on the cert is very very unlikely.

“Also, Washington state does not require any training for someone to attend a homebirth. You can be a doula, or a layperson, and attend a homebirth, even assign APGARs!”

And the home birth subject of the Washington Study had to have a midwife or a physician listed as a home attendant, or they were excluded as home birthers. If they had had a doula, a layperson, (or a dentist) or were alone they would not have been included. So again, the point you raise is irrelevant.

Here’s from the study itself for your viewing pleasure

FROM THE PANG STUDY

“we defined planned home births as those singleton newborns of at least 34 weeks’ gestation who were delivered at home and *****who had a midwife, nurse, or physician listed as either the birth attendant or certifier on the birth certificate****”

“My citations include information about morbidity and mortality from TERM precipitous delivery.”
This study was not about term precipitous deliveries. Compounding its irrelevancy, you fail to show that precipitous deliveries are so likely to occur at home and die that they muck up the data. Most urban précips are hospital, anyway. The they-do-not-make-it crowd are mostly en route, but in any case somewhere in the community. They were not classified as at home. NONE OF THEM HAVE MIDWIVES AND PHYSICIANS WITH THEM COMING IN FROM THE OUTSIDE, LIKE IN THE STUDY’S CRITERIA .

It was about deliveries, all of which were with a midwife or a physician, and part were (intended) at home vs. hospital. What does precipitous have to do with this? Unless you there were a dozen or more precipitous delivery deaths of women who just happened to have had their midwife-friends over for coffee at the time it happened (or their dentist husband who got mistaken for a doctor by himself when he filled out the birth cert).

I assume you are now talking about the Wax Meta, since you have, without transition, switched to it.

“The analysis excluding studies that included home births attended by other than certified or certified nurse midwives had findings similar to the original study, except that the ORs
for neonatal deaths among all (OR, 1.57; 95% CI, 0.62–3.98) and nonanomalous (OR, 3.00; 95% CI, 0.61–14.88) newborns were not statistically significant.”

Midwives tend to be so bad they kill in utero during labor, so the babe is classified as a stillbirth, and left out of the newborn death rates. The data from Johnson and Daviss, for an example, shows a rate of about 5 out of 5000 for a rate of 10/10, 000. The rate for low risk North American stillbirths during labor is about 3/10,000 or less than a 1/3 of the midwives. Also, there’s international data from place like The Netherlands, where midwives control both the home and the hospital and are equally bad in both places and do poorly compared to other western countries. These are not things to celebrate. American women are mostly interested in the choice between home with midwife or hospital with obstetrician.

But these things are logical, facts, and citations. Not that that will stop you from deceiving women about the safety of midwives anymore than it stops you from calling yourself a medical student when you are really an osteopathic student.

Funny how you keep skipping over the word “nurse” when you refer to *****who had a midwife, nurse, or physician listed as either the birth attendant or certifier on the birth certificate****”

Some nurses ride with EMT crews. Some EMT’s are actually nurses who find that EMT work pays better. So it’s entirely possible that some home births “attended” by nurses could be unintended home births where the emergency crew arrived just in time to catch the baby. Or transport to hospital, but was noted as “attended by a health professional prior to transport”.

And the category of midwife includes CNM, licensed midwife, and “other midwife”, and there are no standards for who can call themselves “other midwife”. So that could be Aunt Matilda, who just happened to be there when you delivered precipitously at home, and decided that qualified her to check the “other midwife” box on the birth registration.

“If you’re going to complain about paint-by-numbers or a cookbook approach, link to citations about what is wrong with these approaches, critique them specifically, not just with random vague insults, and offer an alternative.”

“And the other funny thing is that I would expect a person who says “I used to teach statistics” to be able to recognize the difference between a neonatal death rate of 3.4 per thousand, and 3.4 per ten thousand (or 0.34 per thousand), and to know which value is smaller or greater than 1 per 1000. ”

I would expect people to know how to read and do math. Appartently you have confused posting on neonatal death rates with those on intrapartum. The latter is the only time I used X/10,000. There was never a mention of anything being “3.4/10,000” any where in the discussion until now. But, oh well.

A Encore Performance for Your Viewing Pleasure

(from the section on neonatal US vs Netherlands, low-risk moms)
She notes, in great detail, the figures from the study. The death rate is 3.4/1000 in home and hospital. It doesn’t register that this is about three times higher than the US, at 1/1000. It doesn’t register that this is bad.

Some Didn’t Count Intrapartum Death (snip discusses US only docs and hospital vs. lay midwives at home) The main reason it doesn’t get studied anymore is because in physicians and their low risk patients, the overall rate is almost non-existant (3/10,000) Lay midwives int he US have been shown to have rates of 10/10,000 or three times higher.

I’m afraid I must apologize for misunderestimating the specificity that was required for you to see the point I was making. Like you, I would also expect people to be able to read and do math.

Let me be very explicit: When you repeated the numbers that Amy R originally mentioned from the de Jonge study, you dropped off a zero, (just like you did again right here), and then proceeded to complain that this is “bad”, and that others did not realize it was “bad”, even though the death rate you were citing was divorced from reality by an order of magnitude.

Here is Amy R’s original statement:
“Neonatal deaths on day 0-7 occurred in 3.4 per 10,000 of each group”. Yes, that’s per TEN thousand, and yes, that is correct. You can recompute this for yourself from the data in Table 2 and Table 3 of the study:
108/321307 = 0.336 per thousand in the home birth group and 55/163261 = 0.337 per thousand in the hospital group.
With intrapartum death added in, the combined death rate is 0.644 for home births and 0.711 in the hospital group. So even with intrapartum death added in, the death rates are still significantly below the 1/1000 which you have cited as a comparable US rate (from an uncited source).

My point was that anyone who was even vaguely familiar with the de Jonge study would have done a double take before claiming a death rate of 3.4/1000 — because there is nowhere, anywhere, in the entire study that any death rates anywhere near that high can be found. None of the specific subgroups studied have a rate higher that 1/1000, not the women over 35, not the non-Dutch women, not the primips.

So I found it somewhat surprising that someone who may be a statistician or a researcher would criticize Amy R’s analysis, when they misread her statements about the Netherlands study, and were not familiar enough with the primary data to recognize that they did so.

I guess you need to explain your unique brand of reading comprehension to me.

“She notes, in great detail, the figures from the study. The death rate is 3.4/1000 in home and hospital. It doesn’t register that this is about three times higher than the US, at 1/1000. It doesn’t register that this is bad.”

The death rate is. Not she says it is. Not whatever study she is reading says it is. But rather it is.

“Figures from the study” is the thing “she notes”.

3.4/1000 is the death rate is when one standardizes up to 28 days, like the rest of the world does.

I understand teachers have these exercises where you can diagram out sentences to better understand what the subjects and objects of verbs are.

OK, so now you are saying that you were referring to the neonatal mortality rate for ALL births in the Netherlands, all risk levels, all gestational ages. Which is 3.5 per thousand (in 2004). And you were comparing this to a US rate of 1 per thousand, which came from exactly where? From a set of low-risk full-term singleton births? It is nowhere near the overall national neonatal mortality rate, which according to the CDC was 4.52 per thousand in 2004. Ah, but these numbers are not completely comparable, since the EURO-Peristat project counts only births and deaths after 22 weeks. So we can use the CDC wonder database to derive a neonatal mortality rate for 2004, counting only 22 weeks gestation and up. And the answer is……..3.51 per thousand. (United States Department of Health and Human Services (US DHHS), Centers of Disease Control and Prevention (CDC), National Center for Health Statistics (NCHS), Office of Analysis and Epidemiology (OAE), Division of Vital Statistics (DVS), Linked Birth / Infant Death Records 2003-2005 on CDC WONDER On-line Database. Accessed at http://wonder.cdc.gov/lbd-current.html on Aug 4, 2010 8:17:14 PM

So, if the neonatal mortality rate in the midwife-attending, homebirth-loving Netherlands is “bad”, then why is it the same as the high-tech, electronic-monitoring, OB-led, liability-driven US?

One of these things is true:
either you unintentionally misquoted the death rate from the low-risk de Jonge study in the Netherlands, or you intentionally compared an all-inclusive death rate from one country with a selective low-risk death rate from another country. Which is it?

“Let me be very explicit: When you repeated the numbers that Amy R originally mentioned from the de Jonge study, you dropped off a zero, (just like you did again right here), and then proceeded to complain that this is “bad”, and that others did not realize it was “bad”, even though the death rate you were citing was divorced from reality by an order of magnitude. ”

Oops, lol. I admit, I stopped reading after “cbts” showed a complete lack of understanding of confidence intervals. No wonder he/she/it USED to teach statistics. One can also usually tell how informed a poster is if they have to resort to vitriol rather than sticking to the facts.

I don’t want to get in to any of the heavier details of this conversation, as I’m not well versed in stats or research, but I have to comment about the ridiculous idea that home births only happen in snow storms, or as it seems to have been extrapolated a bit in the comments here to “no truck, snowed in, bridge washed out, or the Baby Daddy from Hell.”

I am friends with a woman who is a child birth educator at a major regional hospital in my area. She recently had her second child. This is a well educated, healthy woman who you would think would know when she was in labor. Yet she didn’t. Her labor wasn’t particularly precipitous. She just didn’t believe she was in labor. She gave birth in her bathroom with her husband (who is really a lovely baby-daddy) catching the baby.

I know someone who is a dentist and is a member of my mother’s country club in FLORIDA who delivered one of his babies on the floor of his house, because of his wife’s extremely precipitous labor. He was the attendant on the birth certificate, and he might have even assigned APGAR scores.

He was hardly the baby daddy from hell, I think their very nice vehicles were in working order, and I am pretty sure there hasn’t been a bad snowstorm in Miami since the Ice Age. She may not have been on cocaine, but the fact that the labor was extremely precipitous makes it much more likely that the baby would have respiratory morbidity and mortality. Oh, and if she was one of the significant number of women who are positive for group B strep, I am pretty sure she was not administered peripartum antibiotics.

Well, that may sound simple to you, but that isn’t a simple statement. Who decides what puts a child in danger? Who says women have the right to select where and how to give birth? Women are refused the right to attempt VBAC all the time. Women are told their choices, whether it be a certain doctor, a certain hospital, or a mode of delivery or type of delivery (i.e. homebirth) is not covered by their insurance, or not even legal in their state. Women have been court ordered to get cesarean sections against their will.

One has to be careful when one says whether or not people don’t have the right to do something. Yes, women may be judged for doing something some people think puts their fetuses or babies in danger, but that doesn’t mean that they don’t have the right.

Why is it so suprising that a group of people would want to limit a woman’s ability to make a choice they believe adversely affects fetal health? Lots of Americans believe abortion should be illegal under the same idea.